The past decade has brought major treatment advances in breast reconstruction surgery. Most notably, autologous flap procedures have vastly improved the patient experience. But despite significant strides on the surgical front, one constant that continues to diminish the quality of life of patients undergoing breast surgery is postsurgical pain. Inadequate pain control after surgery has been correlated with long-term chronic pain,1 which affects between 27% and 48% of patients following breast surgery.2,3

While pain management is integral to an optimal recovery for all surgery patients, given the tremendous psychological and physical disease burden breast cancer patients endure prior to undergoing reconstruction, the need for exceptional postsurgical analgesia is especially critical for this population.

The current standard of care for postsurgical pain management following breast reconstruction consists of a combination of continuous nerve blocks, catheters (anywhere between two and four, in addition to two drains), opioids, and NSAIDs. While effective, the standard regimen has its share of downsides ranging from opioid-related adverse events, which prolong recovery and increase cost of care, to catheter-related issues such as infections at insertion sites, pump errors, and delayed ambulation due to continuous tethering to pain pumps. Despite the well-recognized drawbacks and due to a lack of comparably effective, yet more tolerable alternatives, blocks and pumps have become a fixture in the postsurgical pain-management toolbox.

Enter EXPAREL

A lot changed in 2011 with the US Food and Drug Administration approval of a novel formulation of bupivacaine, called EXPAREL® (bupivacaine liposome injectable suspension). EXPAREL can provide up to 72 hours of local analgesia and reduced opioid requirements via infiltration at the surgical site. Unlike standard bupivacaine, which produces a 6- to 8-hour analgesic effect, the bupivacaine in EXPAREL is encased in liposomes which break down over time to extend the release of the active drug over a 3-day period.

I was initially skeptical about the promise of a non-narcotic local anesthetic that produced prolonged pain relief without catheters, pumps, or IVs, and significantly reduced opioid burden. However, after a few initial cases, it was clear that EXPAREL could greatly enhance the recovery experience of all my patients, especially those undergoing breast cancer surgery and reconstruction.

Evidence Builds

As part of a broader effort to gain formulary acceptance, I conducted a small study with 25 patients to demonstrate the clinical value of EXPAREL in comparison to previous cases using a standard pain regimen (bupivacaine HCl block supplemented by opioid-based rescue, administered via patient-controlled analgesia [PCA]). Patients treated with EXPAREL, half of whom underwent breast reconstruction while the other half underwent aesthetic procedures, reported an average pain score of 3 (using a NRS scale of 1 to 10), compared to 7 for patients who received the standard pain regimen. In addition, patients who received EXPAREL reported being “highly satisfied” with their pain relief.

While the measurable reduction in pain was a key driver of pharmacy acceptance, the cost savings and reduced infection risk associated with the elimination of catheter-based pain control modalities also helped move the needle. Since we added EXPAREL to our pharmacy, I have almost entirely eliminated the use of PCAs, and patients report being more comfortable, able to ambulate sooner, and highly satisfied with their quality of care.

During the past 2 years, I have used EXPAREL in more than 300 cases, including hand and leg surgery, breast surgery, and facelifts, and observed consistent results in terms of pain reduction, opioid reduction, and satisfaction. By controlling pain during the critical few days after surgery without requiring invasive ports, and eliminating high opioid requirements, EXPAREL allows reconstructive surgery patients to focus on the vitally important psychological and practical aspects of healing from a life-changing procedure. Based on my experience, EXPAREL promises to redefine our approach to intraoperative and postoperative pain control.

Tips and Techniques

As a surgeon, I considered myself experienced in local infiltration techniques. However, EXPAREL ® behaves differently from traditional anesthetics, including bupivacaine HCl, in a few important ways. For starters, the liposomal composition makes EXPAREL more viscous than standard bupivacaine, so once placed, EXPAREL remains local and does not disperse.

Unlike Marcaine, which can be liberally applied around the site and massaged into the targeted region, EXPAREL needs precise placement into soft tissues in the region of the sensory nerves, as well as the muscle and fascia, to produce the desired effect. A 20-mL vial of EXPAREL (266 mg) can be expanded with up to 280 mL of preservative-free normal sterile saline for a total volume of 300 mL.

In most of my cases, I will expand the volume to approximately 60 to 100 mL, depending on the surface area to cover. For a DIEP flap, I expand the volume of EXPAREL up to 200 mL and infiltrate the tissues and muscle around the breast and abdomen, as well as the fascial planes (versus the subcutaneous area), and in the region where sensory fibers may be.